The objective of this study was to investigate the efficacy of a
programme of manual therapy and exercise treatment compared with placebo
intervention for patients with chronic rotator cuff disease. The
interventions used were a combined manual therapy and exercise regime,
and a placebo regime that applied sham ultrasound and a light
application of non-therapeutic gel to the shoulder region.

Methods

One hundred and twenty participants were recruited over a three and
a half year period. The participants were randomly allocated to either
the active or placebo treatment groups. Both groups received 10 sessions
with a physiotherapist; one session per week for ten weeks. The active
treatment group received a standardised manual therapy regime that
incorporated soft tissue massage, passive glenohumeral joint
mobilisation, scapular retraining, postural taping and spinal
mobilisation. The active treatment regime also included a home exercise
programme incorporating general strengthening exercises, scapular
stabilisation and postural correction. On completion of the supervised
treatment sessions, the active group was instructed to continue their
home exercise programme for a further 10 weeks. The placebo group had no
further intervention after the initial ten treatment sessions. A variety
of validated outcome measures were used at baseline (prior to
intervention), at 11 weeks (immediately after treatment) and at 22
weeks.

Results

Both groups achieved a statistically significant in-group
improvement during the assessment period. At the 11-week assessment,
there were no significant differences between treatment groups in any of
the primary outcome measures used. However, the active group did show
significantly greater improvements in some secondary measures, these
were; self reported and objective measures of strength.

At 22 weeks, the active group demonstrated a statistically
significant advantage compared with the placebo group in one primary
measure; the Shoulder Pain and Disability Index (SPADI). The authors
state that several other secondary measures favoured the active
treatment group; shoulder pain and disability index function score,
muscle strength, interference with activity and health related quality
of life.

Conclusion

A combination of interventions of manual therapy and exercises did
not distinguish the groups in the short term. It was postulated that,
given the significantly greater improvements in the active treatment
group, the benefits of manual therapy and exercise might be more
apparent in the longer term. The authors also state that physiotherapy
may be more relevant for improving function rather than pain in rotator
cuff disease. If pain is the primary problem, medication or cortisone
injection may be more appropriate treatment options.

Commentary

This study has been conducted with robust methodology. The
standardised treatment intervention applied to the active treatment
group is described in detail in the paper by Bennell et al (2007). This
treatment intervention is holistic and covers a broad range of standard
physiotherapy manual therapy and exercise regimes. Therefore, the
intervention is pertinent to current, usual physiotherapy treatment for
rotator cuff disease. The primary outcome measures were the SPADI,
average pain on movement (numerical rating scale) and participants
perceived global rating of overall change.

The only statistically significant difference between groups
involving the primary outcome measures was in the SPADI at 22 weeks. The
authors report that several secondary measures favoured the active
treatment group at 22 weeks but do not report the statistics for these
measures; therefore, it is assumed that whilst the treatment group
achieved superior results, the between group comparisons were not
statistically significant. The results pertaining to the interventions
are not what physiotherapists wish to read. However the authors explain
in detail the strengths and weaknesses of this study and the various
confounding factors. In reading this paper, one senses some frustration
from the authors that the results did not differentiate the groups more
clearly and that there may possibly have been a clinically acceptable
difference between the groups, if not a statistical difference.

This paper thoroughly reviews and refers to many issues relating to
both the treatment of rotator cuff disease and the research relating to
this topic. The paper clearly outlines the results and compares these
with other related studies. In addition, an in-depth description of the
issues relating to the outcome measures and statistics used in the study
are included. Knowledge of outcome measures and statistics would help
the reader correctly interpret this information, but this is a paper of
interest for clinical physiotherapists.